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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />�i �ri cun �.��f� G � , <br />Installation Company Name and Con�aci In(dS� CC' Q; r.�� /4.a=;1.�4la —L�lr`i s�: <br />T� <br />Dale Back�t�afer Preven6on device (BWD) v�as installed:�D��i \' Date this form :vas completed:—�� <br />Ins�allation Property Owner Name and Contact Info: ��Y11'� i� ii�� I� hr 7. ��., � i.; ;c, _i., r� c <br />Property Address� ,�J���C� <br />Pre•Installation Inspection Checklist: <br />All items must be checked 'Yes' in orde� (oi a 8WD to Ce considered (or installation <br />�t.g.�e I <br />Is there a basement or kvel of the house fhat is at or near 2ssumed sewer main elevationl �}'Yes ❑ No <br />Are there fixiures in the house located belo;v the ups(ream sevrer manhole rim elevation? �Yes ❑ No <br />Is the side sewer currenlly UNPROTECTED frorr seever backups (does not have a BWD insfalled)? � Yes ❑ Uo <br />Site Inspect?on Checklist: <br />A!1 items must be checked'Yes' betore inspection is considered complete % <br />Was side sev�er TV inspected from building to sevrer main? �Yes ❑ PJo Condition: �(�C1� <br />Does side se�^rer have at least 1% slope trom the building to sewer main? [�Nes ❑ No Describ�: <br />Have all building sev�er drain connections to tre side sewer been identified and located? (�'es ❑ No <br />Have all property storm drainzge conneclions to the : ide sewer been identified and localed? [�'es ❑ No <br />Has property been ovaivated for tlrainage deficiencies �vifh findings communicated lo proper�y owner? �t'es ❑ No <br />Installation Details: <br />lNhal type and brand of BWD was insfalled at ihis site (Clean Check BWV, Grinder pump, etc.): �� � �� <br />Where was ihe device installed (general description, afta�h map)? SF. � �'��•��j �,r�� <br />�Nas there any other setver or storm tlrainage work completed in conjunclion with the BWD vdork? is sa please descrit�e: <br />� /�r„� ii — <br />InstallaUon Checklist: <br />Are all downspoufs and site drainage disconnected From upstream of the BVJD? �i'es ❑ No Commenls: <br />Does BWO posilioning meets minimum slone requirement of >1%? �es ❑ No Comments: <br />Can BWD be pulled ou1 for inspeclion and mainlenance after loosening thumb screa�? � Yes ❑ No <br />Is BNlD locked into the proper position and thumb screw tightened? []1�es ❑ No <br />Circle the BWD cov �nga 'iont over T� dscape area) I Ira(fic load bearing cover (drive surta�) I access hatch (building) <br />NJas property owner s o�vn the lo�alion of Ihe inslalled BWD? �Yes ❑ No Commenls: <br />Property Owners Sic <br />Instailers Signature: <br />Revision: 2. <br />Date: �v'��—%� <br />Date: l/ a / � ( <br />� ��ay, September 12, 207.4 <br />